The term “torticollis,” more commonly known as “wry neck,” describes a clinical symptom in which the head is permanently or temporarily tilted to one side in an abnormal position. At the same time, the chin is often turned toward the opposite side. The cause is usually an imbalance in the cervical spine or, even more commonly, a muscle-related problem in the neck. A single muscle or entire muscle groups are so severely tense, shortened, or affected by spasms that a normal head posture becomes impossible. The most common form in infancy is muscular torticollis, but adults can also suffer from acute torticollis, for example due to cervical dystonia or inflammation. Since the condition severely limits mobility and causes pain, a medical evaluation is strongly recommended.

Torticollis severely limits the patient’s range of motion. Those affected experience impaired vision. Their ability to communicate with others is severely hindered.

Torticollis is an extremely rare condition. It is either congenital or acquired. An acquired case of torticollis can be caused, for example, by

an accident,
a surgical procedure resulting in significant scarring,
injuries,
infections, and
various types of rheumatic diseases

The misalignment is often not permanent but occurs involuntarily. The neck may then be unable to straighten at all, or can only be straightened briefly and with severe pain.

There are different forms of torticollis depending on the cause, and the severity of the impairment can vary.

In addition, medical professionals also distinguish between the different types of lateral tilt of the head:

Laterocollis: The head is tilted toward the shoulder.
Rotatory torticollis: The patient constantly turns their head, as if trying to shake it.
Anterocollis: The head and neck are tilted forward.
Retrocollis: The head and neck are tilted backward.
Mixed forms of torticollis: For example, the head is tilted to the side and also rotated.

In torticollis, only the muscles connected to the cervical spine are affected. This is crucial for diagnosing torticollis. If the neck muscles originating from the patient’s head are affected, it is not torticollis.

Forms and Causes of Torticollis

Torticollis can have various causes. Depending on the cause, the following forms are distinguished.

Muscular torticollis

Muscular torticollis is congenital or develops during the birthing process. It is usually clearly recognizable in newborns after 7 to 10 days. The child turns their head toward the healthy side.

The cause of this early-infancy misalignment is a shortened sternocleidomastoid muscle (musculus sternocleidomastoideus). This muscle is one of the large neck muscles and is located on each side of the head.

In congenital muscular torticollis, the right sternocleidomastoid muscle is affected in most cases. Its muscle fibers are excessively surrounded by connective tissue at their lower end. As a result, the shortened neck muscle cannot function properly.

Congenital muscular torticollis often occurs alongside other congenital anomalies, such as

clubfoot and
hip joint malformations such as hip dysplasia

. In hip dysplasia, the hip socket is malformed.

Doctors attribute these deformities to an unfavorable position of the child in the uterus. One of the neck muscles can also be damaged during birth if the infant’s neck is subjected to excessive pressure.

The bruise caused by an injury during birth heals over time. The swelling in the neck muscle area that occurs alongside muscular torticollis usually subsides as well. Then both neck muscles can function with the same strength again.

Osteal torticollis

Osteogenic torticollis is caused by a bone malformation. Some vertebrae in the cervical spine are malformed or misaligned relative to one another.

Osteogenic torticollis is either congenital (Klippel-Feil syndrome) or acquired. For example, a fracture in the cervical spine that has not healed properly can lead to torticollis.

Spastic torticollis

Spastic torticollis (also known as spasmodic torticollis) is caused by neurological damage in the brain. It is also called cervical dystonia. It results from a malfunction in the area of the brain responsible for controlling the muscles that move the head.

Spastic torticollis also causes pain.

Children are most commonly affected by this form of torticollis. Most of them tilt their bodies to one side to compensate for the misalignment of the head. This can lead to the development of additional symptoms.

Infectious Torticollis

The tilt of the head can also have bacterial causes. Such infectious torticollis is a consequence

a throat, tonsil, or laryngitis infection that was not properly treated with antibiotics,
an abscess in the neck area, or
inflamed lymph nodes in the neck.

Because the patient is in severe pain, they automatically adopt a protective posture, tilting their head toward the affected side.

Acute Torticollis

Acute torticollis is usually the result of cervical spine syndrome. This is the medical term used to describe all symptoms associated with damage to the cervical spine.

Possible causes include an accident (whiplash) or signs of wear and tear.

Other Forms of Torticollis

Torticollis caused by scarring results from neck surgeries and neck injuries. A large scar can lead to shortening of the neck muscle.

There are also ocular torticollis and otogenic torticollis. In these cases, the lateral tilt of the head is caused by impaired vision on one side or hearing loss in one ear. Patients intentionally tilt their heads to one side in order to see or hear better.

Rheumatic torticollis is caused by various types of rheumatic conditions affecting the cervical spine. The affected person tilts their neck to the side to alleviate pain through this protective posture.

Some forms of torticollis resolve on their own after a while, while others persist for life.

Symptoms and Diagnosis of Torticollis

Torticollis is visible to the naked eye. The head is permanently or temporarily tilted to one side and is sometimes even twisted. Some patients experience pain in the cervical spine. The affected muscle is also swollen.

People who suddenly notice this type of postural abnormality in themselves should definitely seek treatment from a specialist. Otherwise, there is a risk of serious complications.

For optimal treatment, the orthopedic specialist must first identify the cause of the misalignment. To do so, they use imaging techniques

X-rays,
magnetic resonance imaging (MRI), and
computed tomography (CT)

. Electromyography is used to measure the electrical activity of the muscles.

In some cases, an examination of vision or hearing by an ophthalmologist or an ear, nose, and throat (ENT) specialist may also be necessary.

Neck tie
For some forms of torticollis, a neck brace can also be helpful © Pixel-Shot | AdobeStock

Treatment of Torticollis

Treatment for torticollis depends primarily on the cause of the misalignment.

Congenital muscular torticollis should be treated as soon as possible. If left untreated, it can lead to chronic spinal curvature (scoliosis). In addition, growth may be restricted on the side of the face that is tilted to the side.

Affected children should only lie on their back or side. Physical therapy exercises stretch the shortened neck muscle and move the neck in the opposite direction to help the child regain a natural head posture.

If these therapeutic measures are unsuccessful, surgery is the next treatment option.

During the procedure, the surgeon cuts the sternocleidomastoid muscle at its attachment to the sternum. The surgeon then immobilizes the patient’s head using a neck brace or a plaster cast and keeps it still for up to four weeks.

Spastic torticollis is treated with Botox injections. Botulinum toxin is a neurotoxin produced by certain bacteria. It is most commonly used for wrinkle reduction in cosmetic medicine. In cases of torticollis, it is intended to restrict the range of motion of the muscles in the affected region.

Alternatively, the patient may undergo surgery or receive brain stimulation.

Infectious torticollis is treated with antibiotics.

Although osseous torticollis can be treated surgically, this does not always completely resolve the underlying cause.

Patients with acute torticollis are fitted with a custom neck brace to correct the tilt. To relieve pain, the patient is prescribed medication such as ibuprofen.

FAQ: The 8 Most Important Questions About Torticollis and Neck Tilt

What are the typical symptoms of torticollis?

The main symptom is a visible tilt of the head. The head is tilted to one side, while the chin points toward the unaffected side. This forced posture is often accompanied by swelling of the neck muscles, pain in the neck and upper back, and limited mobility of the cervical spine. In chronic cases, facial asymmetry may also develop. If the torticollis is acute, the symptoms appear suddenly and severely.

What is congenital muscular torticollis?

Muscular torticollis is a congenital form of torticollis that is usually noticeable shortly after birth. It is caused by unilateral shortening or scarring of the sternocleidomastoid muscle, often due to a constrained position in the womb or birth trauma. The muscle partially transforms into connective tissue, which prevents it from stretching. Without treatment, this muscular torticollis leads to permanent damage to the spine and face.

What is spastic torticollis?

Spastic torticollis (also known as spasmodic torticollis) is a form of dystonia. It is a neurologically caused movement disorder in which the brain sends incorrect signals to the muscles. This leads to involuntary, painful spasms of the neck muscles, which repeatedly or continuously pull the head jerkily to one side. This form of cervical dystonia is usually acquired and occurs in adulthood.

Is there such a thing as acute torticollis?

Yes, acute torticollis (torticollis acutus) is actually very common. It often develops overnight, for example after sleeping in an awkward position or due to a draft (torticollis rheumaticus). It involves painful tension in the neck muscles, often accompanied by a blockage at a vertebra. This form is usually harmless and resolves on its own after a few days with heat and rest.

What are the rare forms of torticollis?

In addition to the muscular forms, there is osseous torticollis (torticollis osseus), which results from bony malformations of the cervical spine, such as in Klippel-Feil syndrome. Infectious torticollis (torticollis infectiosus) can result from abscesses in the throat. Even ear problems (otogenic torticollis) or a visual disturbance in which the patient tilts their head to avoid double vision (ocular torticollis) are possible causes.

How is torticollis treated?

Conservative treatment is the first line of treatment. For muscular torticollis, physical therapy and targeted exercises help stretch the shortened muscle. For spastic torticollis, injections of botulinum toxin (Botox) are often the treatment of choice to paralyze the overactive muscles. Acute torticollis is treated with heat and pain relievers.

When is surgery necessary?

Surgery is considered if conservative treatment fails. In congenital muscular torticollis, the shortened muscle is surgically severed or lengthened to normalize head posture. In cases of severe bony deformities, surgical intervention on the bony structures of the cervical spine may also be necessary to ensure stability.

What happens if torticollis is left untreated?

An untreated torticollis, especially in childhood, leads to permanent asymmetries of the face and skull (plagiocephaly). In addition, the body attempts to compensate for the misalignment, which can lead to a curvature of the spine (scoliosis). Chronic torticollis in adulthood often leads to chronic pain and severe wear and tear on the joints of the cervical spine.

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